Letter to Alex Azar, Secretary of the Dept. of Health and Human Services, and Seema Verma, Admin. of the Centers for Medicare and Medicaid - - Grassley Joins Bipartisan Letter to HHS to Advocate for Relief for Senior Adult Communities and Health Care Workers - Grassley Seeks Details of Federal Response to Coronavirus in Nursing Homes

Letter

Dear Secretary Azar and Administrator Verma:

I write today concerning unique challenges facing some of the health care providers that
Congress has designated to receive COVID-19 relief under the Public Health and Social Services
Emergency Fund, established by the CARES Act. In allocating these Federal resources, I urge
that your Department respond directly and promptly to these challenges.
Specifically, I am troubled by media reports concerning the plight of older Americans
who reside in skilled nursing facilities, group homes, and assisted or independent living facilities.

Nursing homes became one of our nation's first so-called "hotspots" for COVID-19 last month,
when the Life Care Center nursing home in Kirkland, Washington initially reported 37 deaths at
the outset1 of this public health crisis. Since then, the number of deaths due to COVID-19 in these facilities has soared to at least 5,670. In at least one State, the percentage of COVID-19
related deaths in long-term care facilities is higher than that of hospitals, and in my home State
of Iowa, nursing home residents account for a majority of COVID-19 related deaths.

The rapid transmission of this respiratory virus in long-term care facilities is attributable
to asymptomatic staff members and residents, the close quarters in which people live, and
staffing shortages, among other factors. The death toll due to COVID-19 among these
residents--especially those with preexisting conditions--is concerning. It is also concerning that
nearly two-thirds of the nation's nursing homes were cited for infection control failures in the
recent past. Such factors underscore the importance of encouraging coronavirus testing and
compliance with CDC guidelines for reducing COVID-19 transmission in these facilities. It also
is important to ensure that any Medicaid- and Medicare-funded facilities accepting COVID-19
patients have adequate staffing, equipment, and other necessary safeguards in place.

A second area for concern is inconsistencies in data tracking. Media accounts suggest
that the Federal government is tracking neither outbreaks nor the number of COVID-19 related
deaths in long-term care facilities.9 This responsibility falls to the States, rather than HHS, but
the lack of uniformity across States in COVID-19 data collection practices makes it difficult to get a true picture of the full impact of this crisis. (To illustrate: some States, but not others,
combine reported data for both residents and staff of long-term care facilities.)11 Given the lack
of consistently reported data, I encourage you to exercise additional leadership in this area, e.g.,
by issuing guidance for states to promote uniformity in the tracking and reporting of COVID-19
cases in nursing homes, assisted living facilities, and other long-term care facilities participating
in the Medicaid and Medicare programs. I also encourage HHS to issue guidance, if it has not
already done so, to ensure the prompt reporting, within 24 hours, of positive COVID-19 results
to the family members of residents of long-term care facilities.

A third challenge is that many long-term care facilities are short on the personal
protective equipment that helps prevent COVID-19 transmission among employees.
Indeed, in at least one nursing home, employees ceased showing up for work due to fear of contracting the
coronavirus.Such incidents underscore the importance of making face masks, gowns, gloves,
and other essential protective equipment available to those who are on the front lines in serving
the elderly and disabled during this public health emergency.

Fourth, transparency is critically important to reassure policymakers and the public that
the Public Health and Social Services Emergency Fund is fully devoted to those in need and
having the capacity to effectively use such resources. I commend the Department for already
doing the necessary outreach to Congress concerning its allocation of $30 billion from this Fund;
and I encourage you to expand on current practice, by reporting at least weekly to Congress with
detailed information on additional Fund expenditures.
In light of the importance of swiftly responding to this public emergency, I ask that you
respond to the following no later than April 23, 2020:
1. Please describe CMS plans, if any, to update its guidance or training requirements on
infection control procedures, especially for personnel in nursing homes and other longterm care facilities.
a. What plans, if any, does HHS have to revisit and update 42 C.F.R. § 483.80,
which outlines the requirements for infection control specialists in these facilities?
2. Does HHS have the authority necessary to promulgate regulations calling for more
uniform reporting of COVID-19 infections by State public health agencies?
a. If not, what Federal legislation would be necessary to close such gaps in HHS's
regulatory authority?
3. Please provide a detailed proposal on the planned use by HHS of the $100 billion in the
Public Health and Social Services Emergency Fund (the "Fund"). Please also include a
detailed accounting of the allocation of the $30 billion that has been distributed to date by
HHS, including a discussion of the criteria used to determine which health care providers
are eligible for assistance.
a. To what extent have long-term care facilities, including nursing homes, group
homes, assisted living facilities, and independent living facilities across the
United States received resources flowing from the Fund? For what purpose(s)
may these funds be used by such providers?
b. Is the purchase of personal protective equipment a permitted use of Fund
resources by all health care providers, or is participation in Federal health care
programs, such as Medicare or Medicaid, a precondition for such assistance?
c. What additional efforts has HHS initiated to ensure that all health care providers
have access to personal protective equipment?
d. Have some health care facilities, such as independent living facilities that do not
participate in either the Medicare or Medicaid programs, been ruled ineligible for
the Fund's relief assistance? If such facilities are ineligible, does HHS have other
plans or recommendations to assist these facilities? Please explain.
4. Has HHS issued (or does it plan to issue) coronavirus testing protocols for employees of
long-term care facilities?
5. In guidance issued on April 2, 2020, CMS embraced the idea of establishing separate
wings in long-term care facilities for residents that have contracted COVID-9.
Arethere practical impediments for many of these facilities to the implementation of this
approach, and to what extent have such facilities adopted it in practice?
6. Because some employees of long-term care facilities reportedly lack expertise in
management of medical emergencies, proper use of personal protective equipment, and
appropriate handwashing procedures, does HHS have any plans to expand its guidance
and training requirements to cover such topics?15 Please explain.
7. By law, a long-term care facility must report a positive COVID-19 case, outbreak, or
related death to state or local authorities, and this information then is relayed to the
CDC.16 Approximately how long, on average, does it take for the CDC to transmit such
information to HHS and CMS?
a. A leading trade association for the nursing home industry recently encouraged its
members to report every positive COVID-19 test result to the appropriate State
survey agency as well as the residents, family members, and staff of each such
nursing home. Has CMS considered imposing a similar requirement for all
nursing facilities that participate in the Medicaid and Medicare programs?

Thank you for your attention to this matter. Please contact Evelyn Fortier of my staff at
202-224-4324 if you have any questions.

Sincerely

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